University of Pennsylvania School of Medicine SURVIVAL GUIDE TO THE CLINICS January 2011 Introduction Your current transition from the basic sciences to the clinics is naturally intimidating You’ll soon be immersed in an unfamiliar environment that will demand greater responsibility and commitment than anything you’ve previously encountered in medical school Despite how awkward your white coat may feel, you are more than ready to begin navigating the corridors of HUP While your clerkship year will occasionally be anxiety-provoking and exhausting, it will more often be exhilarating, exciting and incredibly fun You’ll see the practical application of the things you’ve learned, interact daily and influentially with patients, become a valuable member of medical and surgical teams, and finally sense yourself becoming a true clinician This guide is intended to help ease your transition into the clinics You’ll soon realize that each rotation and each site has its own distinct flavor What is expected of you as a student will vary from one rotation to the next Rather than attempt to describe the specifics of every rotation, this Survival Guide presents general objectives, opportunities and responsibilities, as well as some helpful advice from previous students Above all, your fellow classmates and upper-classmen should be a tremendous resource throughout this core clinical year Enthusiasm, dedication and flexibility are the keys to performing well and learning in the clinics Throughout your clinical experience, you’ll interact with an incredibly diverse group of attendings, residents and students in a variety of medical environments If you can adjust to these different situations, maintain enthusiasm, curiosity and integrity, you will certainly be successful and have fun Table of Contents Introduction Table of Contents _4 Acknowledgments _6 Helpful Hints _7 The Team Other Important People Organization 11 Rounds _11 Pre-Rounds 12 Work Rounds 13 Attending Rounds 14 Topic Presentations _15 Call 15 The Chart _16 The H&P 16 Progress Notes _20 Pre-OP Notes 21 OP Notes 22 Post-OP Notes _22 Delivery Notes 23 Post-partum Notes _24 Orders _24 Admission Orders 25 Prescription Writing 26 Filling your White Coat _26 Phlebotomy _27 Paging/Cellular Phones _28 Module 4: Core Clerkships 29 Medicine and Family Medicine _29 Inpatient Medicine 29 Family Medicine _36 Pediatrics/Obstetrics & Gynecology _38 Pediatrics _38 Obstetrics & Gynecology 43 Common OB/GYN Abbreviations _46 Psychiatry/Neurology/Ophtho/ENT/Ortho _48 Psychiatry _48 Neurology _51 Ophthalmology 52 Otorhinolaryngology 53 Orthopedics _53 Surgery/Emergency Medicine/Anesthesiology _53 Surgery _53 Emergency Medicine 61 Anesthesiology _62 AOA Guide to Review and Textbooks _ 63 Exposure to Blood and Body Fluids _69 Transportation 72 Quick Phone Reference _75 HUP Acceptable Abbreviations _78 Sample Patient Write-ups _89 Sample Topic Presentations 106 Acknowledgements This guide has been revised throughout the years, and could not exist in its present form without the efforts of previous writers and editors, as well as the experience and advice of previous students Special thanks goes to Barb Wagner and Erin Engelstad for helping to provide this information to students so that they may feel better prepared as they enter the clinics We hope you find this guide helpful during your transition into the clinics Your attendings, residents and fellow students will be very encouraging and supportive throughout your rotations Again, you are not expected to know everything, only to learn a little more each day Trust that your comfort, confidence and abilities will increase with experience Maintain your enthusiasm and curiosity Above all, don’t forget to relax and have fun Best of luck, AOA Class of 2011 Helpful Hints • • • • • • • • • • • • • • • • • • Being a team player is as important as a strong fund of knowledge Stay organized Don’t be afraid to ask for help Don’t be afraid to ask questions Be friendly to nurses and clerks—they can teach you a great deal about your patients and about how things are done in the hospital Be concise but complete Be assertive but not obnoxious Take some time to learn your way around the different parts of the patient chart early on Do the same with the computer system Always be prepared and on time for rounds Know your patients well Respect your residents and attendings, but not kiss up Insincerity is obvious Learn the many ways to say sincerely “I don’t know”—tough questions aren’t always intended to evaluate you, but often to provide a starting point for teaching Ask for feedback midway through the course to help you redirect your efforts if necessary and avoid surprises at the end of the rotation Do not despair if you receive an unfair evaluation Almost everyone gets at least one unexpected grade in the course of their clinical rotations Do not intentionally show up a classmate—news travels fast Don’t spend too much time on MedLine/OVID/Pubmed searching for the most recent articles Concentrate on the basics Consult your classmates They are your greatest resource Don’t worry about your grades compulsively They should not be your primary motivation in the clinics Relax, smile and laugh naturally An easy-to-get-along-with, interested, and enthusiastic student will well When in doubt, just focus on doing things that will help your patients No one expects you to know everything That’s why you’re here The Team ***A note on what to call people: interns and residents will almost definitely want you to call them by their first names, so feel free to that from the start Fellows will probably want you to call them by their first names too, but you could start with Dr Soandso if you feel nervous With attendings, always start with Dr Soandso, but if they tell you to call them by their first names feel free to so Intern: The intern, also known as a PGY-1 (post-graduate year 1), is in his/her first year as an MD and has primary responsibility for the day-to-day needs of the patients He/she is often overworked and sleep-deprived and will gladly welcome any help provided by students Many interns will return the favor with informal teaching sessions related to routine work on the floor Expect to spend much of your time with the intern They can be an incredible source of information in preparing presentations and caring for patients While on some rotations they not directly evaluate medical students, on others they do, and chiefs and attendings often ask for their input at the end of the rotation Resident: Residents are also known as PGY 2s, 3s etc or sometimes JARs and SARs (junior and senior admitting resident) This person makes certain that the team runs smoothly, makes routine patient care decisions, and oversees the activities of the interns and medical students Their responsibilities will vary depending on their level of training and specialty Residents have had more years of experience and often have the most time and interest in teaching about various topics during your rotation The resident evaluation is a major component of the medical student grade, along with the attending evaluation Fellow: After having completed residency training in a general field, these individuals are pursuing specialty training as clinical fellows For example, after completing seven years of training in general surgery, physicians may elect to spend three additional years of training as fellows in cardiothoracic surgery The exact responsibilities of fellows depend on their position and field of interest While your contact with fellows as a 200 student will be limited, you will undoubtedly encounter them when you consult subspecialty services, in the clinics, and in the operating room House Staff: All physicians in training are collectively referred to as house staff/house officers Extern/Sub-Intern (Sub-I): A senior medical student who is taking an advanced course in which they take on many of the responsibilities of an intern The Extern technically is an additional student member of the team, whereas a Sub-I takes the place of an intern on a team Attending: The attending physician has completed formal training and finally has a real job Attendings have titles such as assistant professor, associate professor and professor depending on their level of experience within the department The attending is ultimately responsible for the care of patients on your service and accordingly will make all major decisions regarding patient management He/she runs attending rounds and is the person to whom you will present your patients The attending is often the person who asks you the most questions, and he/she is usually responsible for writing your primary evaluation for the team While you should try to spend as much time with your attending as possible on the floor, in clinic, and in the OR, they are incredibly busy and often cannot be available for you Realize that the degree to which your attending will teach you is very individual and discipline dependent Team: The team includes all of the previously mentioned individuals and you The importance of working as a team is paramount It allows work to be completed smoothly and efficiently, provides more time for teaching, creates a more enjoyable environment, and provides for the best care of patients Other Important People: Allied health professionals are essential in the care of patients and can be extremely helpful to the beginning medical student Many of the senior nurses, therapists, and clerks have outlasted generations of students and residents and, by virtue of that experience, deserve a great deal of respect While you may think they’re being excessively critical or suspicious of you at times, it’s only because they’ve seen students make the same mistakes over and over again throughout the years You’ll have to earn the benefit of the doubt Be comforted by the fact that everyone ultimately has the patients’ best interests at heart Nurses: Nurses are in charge of overseeing the routine, yet vital, aspects of patient care Among other things, they implement physician orders, monitor patient vital signs and activities, and administer supportive care Some will insert IVs and perform routine phlebotomy Charge nurses are nurses that supervise individual floors Scrub nurses run operating rooms and maintain the sanctity of the sterile field Nurse practitioners have advanced degrees and are able to perform some of the duties of a primary care physician Nurse’s Aids (who not have an RN degree) assist nurses in obtaining vitals and routine patient care activities Staying on the good side of the nurses, particularly the charge nurse, is always a good idea Ward Clerk: Unit clerks handle floor business: they answer phones, schedule tests, complete paperwork, and generally keep things running smoothly They typically sit at the nurse’s station and are an excellent source of practical information Quickly learn which chair belongs to them, and not ever sit there! Physical Therapy (PT): Physical therapists evaluate and treat patients suffering from physical dysfunction and pain resulting from illness They emphasize motor rehabilitation training in order to help patients regain joint mobility, strength, and coordination Occupational Therapy (OT): Occupational therapists also deal with physical dysfunction, but their goal is to help patients (many of whom have cognitive impairments) achieve independence in daily activities through exercise, fine motor skill repetition, and family education Respiratory: Respiratory techs go throughout the hospital to administer nebulizer treatments, perform bedside PFTs (pulmonary function tests), and adjust ventilator settings Social Services: Social workers act as liaisons between the patient and the patient’s care providers, both within the hospital and out in the community They assess the patient’s care network outside the hospital, arrange for nursing home or chronic care placement as needed, and participate in family education and support Nutrition: A service staffed by both MDs and registered dietitians (RDs), nutrition addresses patient care issues such as intravenous nutrition, special diets, cachexia, etc Chaplaincy: Most hospitals, including HUP, offer this service, which provides inpatients (of most denominations) with worship services and spiritual counseling 10 100 SURGERY CC: RLL nodule HPI: Patient is status-post nephrectomy on 3/29/08 for renal malignancy Nodule was identified in pre-op chest CT scan Patient has no respiratory complaints, although he complains of mild pain over his incision He has been active since his nephrectomy and takes no medications for pain PMH: • • • • Type II Diabetes Mellitus Hyperlipidemia Hypertension Atrial fibrillation – single episode which occurred 12 years prior to this visit PSH: • Tonsillectomy & Adenoidectomy • Right nephrectomy Medications: • Actos – 45mg PO qd • Altace – 5mg PO qd • Aspirin – 81mg PO qd • Januvia – 100mg PO qd • Nadolol – 20mg PO qd • Zocor – 20mg PO qd Allergies: NKDA Family History: Patient describes a history of diabetes in his brother and cardiac disease with a history of MI in his father Social History: Patient is not a current smoker but has a 20 pack-year history and quit 10 years ago Patient drinks approximately alcoholic beverages per week, and does not use illicit drugs ROS: GEN: No fevers, chills, weight loss, malaise, fatigue, or weakness HEENT: No headaches, hearing loss, tinnitus, ear pain, or ear discharge; No nosebleeds, congestion, stridor, or sore throat; No trouble with vision, eye pain, or photophobia CVS: No chest pain, palpitations, orthopnea, claudication, leg swelling, or PND Chest: No cough, hemoptysis, sputum production, SOB, or wheezing 101 GI: No heartburn, nausea, abdominal pain, vomiting, diarrhea, constipation, or blood in stool GU: Hematuria – presenting complaint for RCC in 2/08, No dysuria, frequency, urgency, or flank pain Musculoskel: No myalgias, neck or back pain, joint pains, or falls Endo/Heme: No easy bruising or bleeding Neuro: No history of seizures, focal weakness, or dizziness Psych: No history of psychiatric disease, insomnia, or substance abuse Skin: No rash or itching PE: BP 128/71, Pulse 73, Temp 97.5F, Resp 20, BMI 31 Gen: Oriented x 3, well-nourished, no distress HEENT: Normocephalic, atraumatic Eye: Conjunctiva normal, EOMI, PERRL Neck: ROM normal, neck supple, no thyromegaly, JVD, tracheal deviation, or stridor; no lymphadenopathy CVS: RRR S1 S2 noted, no m/r/g, no clubbing, cyanosis, or edema, intact distal pulses Chest: Effort normal, breath sounds normal; no respiratory distress, chest tenderness, wheezing, or rales Abd: S/NT/ND, NABS, no guarding, no rebound Musculoskel: Normal ROM, No edema, No tenderness Neuro: Alert and oriented x Skin: No rashes or change in pigmentation Labs: None Imaging: Indeterminate 7mm nodule in RLL on CT with contrast Impression: Indeterminate lung nodule found incidentally on preop screening CT of the chest Patient asymptomatic and recovering well from recent surgery Plan: Recommend that patient have serial CT scans to follow the lung nodule He will have the next scan in one month and follow-up in the office after that time 102 FAMILY MEDICINE-SOAP Note Patient: CJ S: CJ is a 35 y/o female with PMH obesity, HTN, and hyperfunctioning thyroid nodule (s/p thyroidectomy 2006) who presents with chief complaint of fatigue She states that she is “always tired” and has felt this way for the last year She has been working the night shift at her job for the past six months and thinks this may contribute to her fatigue, but also states she felt tired before her switch at work She gets around hours of sleep during the day and often does not feel well rested upon waking She sleeps alone and does not know if she snores; she does not recall waking up gasping for air at night She denies morning headaches and falling asleep while at work The fatigue has not gotten any particularly worse, but she decided it was time to “get it checked out.” Past Medical History: Medical -HTN: diagnosed at age 32; well-controlled on HCTZ 12.5mg -Thyroid nodule: hyperactive; s/p thyroidectomy 2006 -Obesity: BMI 44; currently researching gastric bypass surgery Surgical -s/p thyroidectomy 2006; patient thinks it was only partial; not on thyroid replacement Medication Hydrochlorothiazide 12.5mg once daily Social Smokes 7-10 cigarettes a day; is trying to quit Denies EtOH, illicit drugs Not currently sexually active Review of Systems: Constitutional: denies weight loss/gain, night sweats, chills, fevers Cardiovascular: denies chest pain, palpitations, dyspnea at rest or with exertion Gastrointestinal: denies nausea, vomiting, diarrhea, constipation, melena, hematochezia, jaundice, abdominal pain Genitourinary: Admits to menorrhagia for 10+ years; uses super tampons on the heaviest 1-2 days of her period Her periods come every 28-30 days and last days Denies bleeding between periods, dysuria, dyspareunia Endocrine: denies polyuria, polydipsia, heat/cold intolerance, change in skin, hair or nails, change in bowel habits Psych: Admits to a depressed mood, difficulty concentrating at work over the last months, decreased interest in activities that she used to enjoy Denies change in appetite, excessive guilt, or suicidality 103 O: T: (not done) BP: 120/82 HR 68 RR 12 Weight: 275 Height: 5’6” (BMI: 44) General: pleasant, overweight woman sitting in chair and reading Neck: 5cm scar over thyroid, normal movements, trachea midline; no palpable masses Cardiovascular: normal sounds; no murmurs, rubs or gallops; normal pulses, no edema, no clubbing or cyanosis Respiratory: symmetric chest expansion and respiratory effort, clear to auscultation Abdomen: no masses or tenderness, normal bowel sounds, no hepatosplenomegaly Genitourinary: deferred; patient had just seen her gynecologist in AM A: Fatigue-the patient has several possible reasons for her fatigue First, she is working the night shift at work, which she is still having difficulty adjusting to and may be affecting the quality of her sleep Given her obesity, she is at risk for OSA, which may explain the reason why she does not feel well rested even after sleep She also had thyroid surgery in 2006; this may have caused hypothyroidism resulting in her fatigue and symptoms of depression The patient also complains of menorrhagia; her heavy periods may be causing anemia that is resulting in the patient’s fatigue, although she is not complaining of chest pain or shortness of breath Finally, the patient has noticed a depressed mood and difficulty concentrating lately; her fatigue may be a symptom of depression Hypertension-currently well-controlled on HCTZ Obesity-the patient has made several attempts to lose weight using diet and exercise; given her young age and motivation, she may benefit from gastric bypass surgery Depressed Mood- the patient currently has 3/9 criteria (depressed mood, fatigue, and difficulty concentrating) for MDD Menorrhagia-patient followed by gynecologist She was told that she may have fibroids, but she has not followed up on this P: Fatigue a CBC-r/o anemia b TSH-r/o hypothyroid c Sleep study-r/o OSA; patient needs test for gastric bypass eval as well d Discussed possibility of switching back to day shift at work e Follow patient’s mood and monitor for other symptoms of depression-consider trial of anti-depressant; patient was not ready to try one today; Wellbutrin may be a good option for mood improvement + smoking cessation HTN a Continue HCTZ 12.5mg once daily with goal BPs [...]... one there all night, or they got a quick morning report from the on-call intern (Try to ask the intern if there is anything you should know about your patient before rounds so that you can present the information to the attending instead of having the intern report the updates But don’t be offended if the intern forgets to touch base with you before rounds, they’re just busy and it’s not intended to. .. structure to the presentation Here is a general outline of how to approach a topic presentation: 1) Try to pick a topic relevant to either a patient you are following or another patient on the service 2) Narrow your topic as much as possible For example, if you choose to do a presentation on heart failure, narrow it to a specific cause (e.g amyloid cardiomyopathy) and then narrow it even further (e.g... may or may not be allowed to write in the patient’s chart You should ask about this on your first day If you are told to write in the chart, this is all you need to do (be sure to leave some space for your attending to write) If you are told not to, you may want to take notes on an extra sheet while you interview the patient so that you can refer to these when you present • Topic Presentations: Your... if they want to do it themselves; signout is key in getting overnight updates on your patients, but the intern may prefer doing all of their signouts at once and then passing the information on to you Review orders to see if there have been any major changes and/or if any consultant recommendations have been implemented Don’t be surprised if the intern knows things that you don’t: they were either the. .. important to state that it is the “Medical Student Progress Note” as well as to include the date and time on all the notes or orders you write Each page of the chart must also have the patient’s name and social security or medical record number There are often 20 stickers printed out at the beginning of the chart with this pertinent patient identifying information You can use these stickers to put on the top... chart 21 Anesthesia: To see patient, or patient seen, note on chart Consultants - if applicable Signature Print name, MS II Pager number OP Notes Op notes are written in the OR (after the completion of the case) to document the procedure and findings At HUP there are stickers that one can fill out and place in the chart at the completion of the case Ask the circulating nurse where to find them Pre-op... either to the emergency department or to the patient’s room, if s/he is already on the floor Before seeing the patient, you should read through the chart, review ordered and current labs, radiological studies, EKG’s, etc and review Medview for past discharge summaries and/or labs When you see the patient, take as complete a history as you can (do NOT rely on the history documented in the chart by the. .. the rotation to see how they want to deal with morning signouts; it’s often helpful if you and the intern can touch base before rounds to go over new information When you see the patient, document his or her vital signs from the night (these will be documented in a chart at the door of the room or bedside), get a subjective response from the patient on his or her condition, and do a physical exam Then,... Occasionally you may need to have the note in the chart before rounds, in which case you can make a photocopy of the note to help you in your presentation However, these notes are very brief and get much easier to write with practice The amount of teaching you will receive during work rounds is variable, depending on the style of the resident and the number of patients on the service, as well as their level of... the night before to discuss the patient and prepare you for questions that the attending will likely ask Remember, you are absolutely not expected to have an answer to every question Attendings will often use a line of questioning to lead off a teaching session and even the hardest questions of the morning are directed to the most junior person in the room first (always you) before it trickles up to ... surprised if the intern knows things that you don’t: they were either the one there all night, or they got a quick morning report from the on-call intern (Try to ask the intern if there is anything... nice touch and adds structure to the presentation Here is a general outline of how to approach a topic presentation: 1) Try to pick a topic relevant to either a patient you are following or another... you can present the information to the attending instead of having the intern report the updates But don’t be offended if the intern forgets to touch base with you before rounds, they’re just busy